Healthcare Provider Details

I. General information

NPI: 1457761405
Provider Name (Legal Business Name): ANDREW BRUBAKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2014
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 SUSAN WAY DR
RICHMOND KY
40475-9694
US

IV. Provider business mailing address

113 SUSAN WAY DR
RICHMOND KY
40475-9694
US

V. Phone/Fax

Practice location:
  • Phone: 859-248-0425
  • Fax:
Mailing address:
  • Phone: 859-248-0425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number060495082
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.003575
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: